Why Doctors Won't Like ACOs

Nobel Prize winning physicist Richard P. Feynman once said: "Smart people (like smart lawyers) can come up with very good explanations for mistaken points of view." A close look at the armamentarium used by physicians suggests that many of them fool themselves into believing that the mere act of caring for patients improves patient outcomes.

But as I've mentioned before in this column, around 50% of medical interventions aren't supported by well controlled, randomized clinical trials--the gold standard in medicine. While this paucity of data may not have been that big of an issue in the fee-for-services world, it's likely to become a nightmare if hospitals and practices sign onto the Accountable Care Organization model that the Centers for Medicare and Medicaid Services (CMS) is promoting. You may be able to avoid that nightmare if your IT team puts in place the right kind of order sets, electronic health record (EHR) alerts, and clinical decision support tools.

CMS' recently published final rules on ACOs require healthcare organizations to meet 33 quality measures. For providers to cash in on a variety of financial rewards, they will have to collect, analyze, and report their success at meeting those quality measures. But before they can do all this data crunching, they actually have to perform; that is, clinicians must offer patients the kind of high-quality care that CMS expects.

If we juxtapose one of these evidence-based ACO measures with a time-honored yet questionable practice internists perform every day, it illustrates the quandary that many docs will soon face.

ACO providers are expected to take blood pressure readings of patients 18 years of age or older, a measure proven to reduce the risk of cardiovascular disease. But nowhere in the CMS list of performance measures is there any requirement to do an EKG on such patients.

Yet every time I see my primary care doc for a routine physical, I'm always given an EKG. And I'm sure millions of other men and women are as well. Why is that?

According to the latest data analysis, summed up in the Journal of the American Medical Association, "rigorous evidence is lacking to determine whether such tests actually change clinical actions and improve outcomes."

Think about how many millions of dollars are wasted doing this procedure, and multiply that amount by all the other unsubstantiated screening, diagnostic, and treatment measures that have been used over the years, and you get a sense of why America is drowning in healthcare costs.

Granted, this analysis oversimplifies the situation because it doesn't distinguish between the application of research data to large populations and its application to a single patient. Put another way: The fact that research indicates that EKG screening doesn't benefit 10,000 patients doesn't necessarily mean it won't benefit Mr. Jones as he sits in Dr. Smith's examining room. There may be circumstances in Mr. Jones' case that make him an exception to the rule. And your EHR still needs to give clinicians the leeway to make that call on a case-by-case basis.

But putting those exceptions aside, for your organization to qualify for ACO dollars it will still need evidence-based guidelines. IT and clinical leaders will need to join forces to tackle these issues. From my discussions with CIOs and CMIOs around the country, several viable options emerge.

One is vendor-supplied order sets. ProVation, for instance, offers evidence-based order sets, based on the reliable content from a medical knowledge database called UpToDate. They can be integrated into a hospital's systems, based on standards such as HL7 and InfoButton API, and the correct terminology, including SNOMED CT, RxNorm, LOINC, CPT, and ICD-9.

I recently spoke with Scott Weingarten, CEO of Zynx Health, which also provides such order sets. When the conversation turned to ACO quality measures, he mentioned the requirement to give influenza immunization as a preventative measure. It makes sense, he says, to have an order set in your CPOE that instructs docs to write a prescription for the vaccine. And to have an alert built into the EHR to remind them if they overlook that task.

You may want to look into several other clinical decision support innovations. The hot areas are personalized medicine, natural language processing, and clinical analytics. If used wisely, they can help improve your organization's clinical outcomes and meet the CMS quality measures. More details on all three developments are available in our November digital issue.

Richard Feynman may be right about our ability to fool ourselves, but when there's this much money at stake, it's amazing how clear-headed and self-critical we can become.

The new InformationWeek Healthcare supplement on EHR Best Practices explains how the most astute healthcare providers are putting those billions of dollars in federal stimulus funds to productive use. Download the supplement now. (Free registration required.)

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